Berjano Pedro, Gautschi Oliver P, Schils Frédéric, Tessitore Enrico
IVth Spine Surgery Division, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy.
Acta Neurochir (Wien). 2015 Mar;157(3):547-51. doi: 10.1007/s00701-014-2248-9. Epub 2014 Oct 31.
First introduced by Pimenta et al. in 2001, the extreme lateral interbody fusion (XLIF®) approach is a safe and effective alternative to anterior or posterior approaches to lumbar fusion, avoiding the large anterior vessels and posterior structures including the paraspinous muscles, facet joint complexes and tension bands.
The authors provide a detailed description of the surgically relevant anatomy focusing on the close relationship among the lumbar plexus, psoas muscle and lateral spinal column. The surgical technique is detailed step by step, stressing how to avoid complications. A video clip of an XLIF is provided, and important perioperative considerations are listed in detail.
The XLIF® approach is a safe procedure allowing an approach to the lateral lumbar spine. Nevertheless, the surgeon's knowledge of anatomical landmarks, response to visual and tactile cues, and intraoperative decision-making skills remain of paramount importance.
• Correct lateral positioning with an orthogonal orientation of the corresponding lumbar vertebral body is of key importance. • Subsequent table repositioning for every level is advised in multilevel cases. • Posterior structures including the paraspinous muscles, facet joint complexes and tension bands are mostly preserved. • Meticulous preoperative planning of the psoas docking point, considering all level-specific vascular and neuronal elements, is of paramount importance. • In general, concavity is recommended for the selection of the approach side. • A careful endplate and contralateral preparation and release are mandatory in order to allow bony fusion and maximum indirect foraminal decompression. • Using a perioperative dexamethasone bolus seems to be effective at the L4/5 level to reduce postoperative plexopathy. • Overdistraction should be avoided in order to prevent cage subsidence. • A major disadvantage is the relatively high, but mostly only transient, incidence of psoas weakness as well as hip-groin-thigh pain, dysaesthesia and/or numbness. • Major advantages include indirect neurological decompression, minimal blood loss, shorter operation times, decreased overall infection rates and more surface for bony fusion.
2001年由皮门塔等人首次引入，极外侧椎间融合（XLIF®）入路是腰椎融合前路或后路入路的一种安全有效的替代方法，可避免大的前血管和包括椎旁肌、小关节复合体及张力带在内的后部结构。
作者详细描述了与手术相关的解剖结构，重点关注腰丛、腰大肌和脊柱外侧柱之间的紧密关系。逐步详细介绍了手术技术，强调如何避免并发症。提供了一段XLIF手术的视频片段，并详细列出了重要的围手术期注意事项。
XLIF®入路是一种安全的手术方法，可用于进入腰椎外侧。然而，外科医生对解剖标志的了解、对视觉和触觉线索的反应以及术中决策技能仍然至关重要。
• 以相应腰椎椎体的正交方向进行正确的侧方定位至关重要。
• 对于多节段病例，建议对每个节段进行后续的手术台重新定位。
• 包括椎旁肌、小关节复合体和张力带在内的后部结构大多得以保留。
• 考虑到所有节段特异性的血管和神经因素，对腰大肌对接点进行细致的术前规划至关重要。
• 一般来说，建议选择凹陷侧作为手术入路侧。
• 为了实现骨融合和最大程度的间接椎间孔减压，必须仔细处理终板和对侧结构并进行松解。
• 在L4/5节段使用围手术期地塞米松推注似乎对减少术后神经病变有效。
• 应避免过度撑开以防止椎间融合器下沉。
• 一个主要缺点是腰大肌无力以及髋部 - 腹股沟 - 大腿疼痛、感觉异常和/或麻木的发生率相对较高，但大多只是短暂的。
• 主要优点包括间接神经减压、失血极少、手术时间缩短、总体感染率降低以及更大的骨融合面积。
